From the very beginning, Heritage deployed people into the community to educate physicians about Heritage, its ACO, and how it planned to operate. Heritage wanted to tell its doctors in Southern California -- 80% of whom belong to independent practice associations -- how working with their ACO would benefit them.

Drew said ACOs were deployed prematurely with a lot of physician misunderstanding about them. Swaying doctors' opinions helped persuade them to get on board with Heritage.

Heritage needed permission from physicians to unleash its care management programs on Medicare beneficiaries within the ACO.

"The more work we could do for them, the more successful it would be," Drew said.

2. Analyze Medicare Patients

Since ACOs are predicated on needing to reduce spending levels on Medicare patients, Heritage knew it needed to learn which patients where costing them the most. The ACO used Medicare claims data to help identify which patients needed their attention.

"Every single one of those patients was called," Drew said. "We spent an hour on the phone with each person and their family."

The ACO learned about social and family issues and other obstacles that needed to be overcome to prevent Heritage from keeping them out of the hospital and emergency department.

Knowing which patients were now at highest risk, Heritage could then deploy a bevy of resources to help them stay healthier -- and in turn lower their costs to Medicare.

They used telemedicine when possible, established patient portals so beneficiaries could better access their information, and used caregivers when possible to prevent hospitalizations and emergency department visits.

Drew described it as doing everything they could to provide care in the patients' home that would otherwise be delivered in the hospital or doctor's office.

Heritage also turned over its in-house information to physicians in its ACO. The organization knew it needed those doctors on board with everything it was doing.

"We in some cases are probably more aware of patients' needs then the doctors are," Drew said.

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